Job Description

This Per Diem Clinical Documentation Integrity Specialist will be responsible for:

• Facilitating clinical documentation to support appropriate diagnosis coding & to ensure the level of service rendered to all patients is accurately reflected.
• Collaborating with HIM coding staff to promote complete & accurate clinical documentation & correct negative trends.
• Communicating with physicians, nurse practitioners, case managers, coders & members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making & medical documentation.
• Assigning a working APR-DRG, severity of illness & risk of mortality using coding rules & guidelines.
• Analyzing clinical information to identify areas within the chart for potential gaps in physician documentation.
• Query physicians on a concurrent basis. Work with clinicians to clarify documentation in the medical record.
• Formulating credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, & patient safety indicators (PSI).
• Conducting post discharge reviews for comparative analysis of CDI Specialist & HIM APR-DRG, adding SOI & ROM assignments. Reviewing clinical issues with the coding staff to assign a working DRG.
• Utilizing software systems (including APR-DRG encoder) to collect, track, & report outcomes. Being proficient in abstraction of data and entry into all databases used for clinical documentation. Maintaining integrity of data.
• Participating in ongoing education of staff.
• Flexibility with schedule. Remote work with in person meetings as needed. Residents of other states may be considered.

• Bachelor?s Degree (Nursing preferred)
• If no nursing background, certification as an inpatient coder or other relevant clinical experience (e.g. MD-equivalent degree) required.
• Clinical inpatient hospital experience preferred.
• CDI Specialist experience in an inpatient setting, preferred.
• Superior communication & interpersonal skills
• Competency in MS Office; experience with Epic EMR preferred.
• Knowledge of the APR-DRG and ICD10 coding preferred.

About Boston Children's Hospital

Boston Children's Hospital is a 395-bed comprehensive center for pediatric health care. As one of the largest pediatric medical centers in the United States, Children's offers a complete range of health care services for children from birth through 21 years of age.

Job Tags

Similar Jobs